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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:39:37 AM


Document Has Been Signed on 09/20/2024 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SILVER LIGHT CAREFACILITY NUMBER:
195850239
ADMINISTRATOR:KHACHATRYAN, ELBAFACILITY TYPE:
740
ADDRESS:8201 VANTAGE AVENUETELEPHONE:
(747) 228-4111
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Edgar KhachatryanTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management – Deficiencies visit at 10:12 AM. LPA met with facility staff who contacted Administrator Elba Khachatryan via telephone call. LPA explained that the visit was in reference to a 3-day eviction notice issued without prior approval from CCL.

On 09/13/2024, LPA Emily Peraldi spoke with Administrator Elba Khachatryan regarding an incident report pertaining to Resident #1 (R1) of which R1 was threatening harm to residents and staff. A 3-day eviction was discussed, and LPA Peraldi advised the Administrator that CCL would need to review and approve the notice prior to issuance. On 09/16/2024, LPA Byrne was advised by the Administrator that they issued the 3-day eviction notice to R1 without CCL approval and R1 relocated on 09/15/2024.

Between 10:14 AM and 10:45 AM, LPA conducted a brief physical plant tour, interviewed staff, interviewed residents, and reviewed pertinent documentation relevant to the incident. Interviews conducted and records review revealed that R1 is no longer residing at the facility. Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) stated that they had overheard R1 making threats to staff previously. Staff 1 (S1) and staff 2 (S2) stated that they had previously been directly threatened by R1.

LPA informed facility staff and facility administrator that all 3-day evictions are required to be approved by CCL prior to their issuance to a resident. The facility administrator was unable to sign the report and has designated facility staff Edgar Khachatryan to sign on their behalf. This report was read to the facility administrator via telephone call.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, appeal rights were discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2024 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87224(b)

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(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause...behavior which is a threat to ...health or safety of others in the facility.
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Licensee will submit a statement of understanding stating that they have reviewed the entirety of CCR 87224 to CCL no later than POC due date.
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Based on interviews and record review the licensee did not comply with the section cited above as R1 was served a 3-day eviction notice without prior approval from CCL. This posed a potential personal rights risk to the client in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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